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| GA Home Self Test Project
Eligibility Survey |
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1.Name |
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2.Date of birth // |
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3.Email |
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4.Phone Number -- |
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5.In what county do you reside? |
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6.What is your 5-digit zip code? |
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7.How did you first learn about the HIV Self-Testing? Check all that apply Social Media Local Health Department GA CAPUS Resource Hub Friend/Referral Other (please specify): |
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8.How would you describe your gender? Male Transgender Male-to-Female Female Transgender Female-to-Male Other gender (specify): |
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9.What is your ethnicity? |
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10.What racial group do you consider yourself to be a member of? Asian Black/African-American/Afro-Caribbean More than one race Native American/Alaskan Native Native Hawaiian/Pacific Islander White Other (specify): |
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11.Do you have health insurance? |
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12.Have you ever been tested for HIV? |
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13.Are you familiar with or have you ever taken Pre-Exposure Prophylaxis (PrEP) for HIV? Check all that apply I am currently using PrEP. I have friends who use PrEP. I have sexual partners who use PrEP. If my sexual partners take PrEP, I'm at less risk of becoming infected with HIV. If I take PrEP, I'm at less risk of becoming infected with HIV. I have never heard of PrEP PrEP should be used with other HIV prevention measures. None of these are true. |
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14.Why do you want a home HIV home self test kit? Check all that apply Distance from Testing Site Transportation to Testing Site No childcare In-Home Privacy Confidentiality Nervous to take a test at a clinic Use with partner Observing Social Distancing Other (Please specify): |
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15.How would you like to receive your test kit? Mailed to me |
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Picked up at local location 15.a How many kits would you like to request? |
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What is the zipcode or county where you will pick up your test kit? or County | ||||
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12a.When was your last HIV test? |
Date of Survey:
09-JUN-23
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Date of Survey:
09-JUN-23
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